Orthognathic Surgery Patients (Maxillary Impaction and Setback plus Mandibular Advancement plus Genioplasty) Need More Intensive Care Unit (ICU) Admission after Surgery.

STATEMENT OF THE PROBLEM
Due to shortage of ICU beds in hospitals, knowing what kind of orthognathic surgery patients more need ICU care after surgery would be important for surgeons and hospitals to prevent unnecessary ICU bed reservation.


PURPOSE
The aim of the present study was to determine what kinds of orthognathic surgery patients would benefit more from ICU care after surgery.


MATERIALS AND METHOD
210 patients who were admitted to Chamran Hospital, Shiraz, for bimaxillary orthognathic surgery (2008-2013) were reviewed based on whether they had been admitted to ICU or maxillofacial surgery ward. Operation time, sex, intraoperative Estimated Blood Loss (EBL), postoperative complications, ICU admission, and unwanted complications resulting from staying in ICU were assessed.


RESULTS
Of 210 patients undergoing bimaxillary orthognathic surgery, 59 patients (28.1%) were postoperatively admitted to the ICU and 151 in the maxillofacial ward (71.9%). There was not statistically significant difference in age and sex between the two groups (p> 0.05). The groups were significantly different in terms of operation time (p< 0.001). Blood loss For ICU admitted patients was 600.00±293.621mL and for those who were hospitalized in the ward was 350.00±298.397 mL. Statistically significant differences were found between the two groups (p< 0.001). Moreover, there was a direct linear correlation between operation time and intraoperative estimated blood loss and this relationship was statistically significant (r=0.42, p< 0.001). Patients with maxillary impaction and setback plus mandibular advancement plus genioplasty were among the most ICU admitted patients (44%), while these patients were only 20% of all patients who were admitted to the ward. As a final point, the result illustrated that patients who were admitted to the ICU experienced more complication such as bleeding, postoperative nausea, and pain (p< 0.001).


CONCLUSION
Orthognathic surgery patients (maxillary impaction and setback plus mandibular advancement plus genioplasty) due to more intraoperative bleeding and postoperative nausea and pain would benefit from ICU admission after surgery.


Introduction
Orthognathic surgery is used to correct facial anatomy in patients with dentofacial disorders as a part of fre-quently-performed hospital surgeries. This surgery results in a considerable blood loss to the extent that patients undergoing such operations sometimes need blood transfusions. The reason for such considerable blood loss is the high vascular nature of the maxillofacial area as well as the difficulty of access to the area under surgery for hemostasis purposes. [1] Currently, orthognathic surgeries are performed most frequently. [2] One of the most serious risks of bimaxillary orthognathic surgeries is severe blood loss during such operations. [3] Among the most important challenges that anesthesiologist and surgeons usually face are intraoperative bleeding during orthognathic surgery, the need for transfusion of blood products, postoperative pain, side effects such as nausea and vomiting, postoperative agitation and shivering, severe swelling due to airway manipulation and extent of surgery, and intermaxillary fixation. Therefore, some orthognathic patients need special hospital care for continuous monitoring of vital signs and nursing interventions. On the other hand, undesirable side effects of intensive care unit (ICU) admission such as resistant infections in the hospital, unknown fever, nosocomial pneumonia, long-term problems of keeping the endotracheal tube, overdosing the patient with sedating agents to tolerate ventilator system could jeopardize the patient's health. [4][5] ICUs cater for patients with the most severe and life-threatening illnesses and injuries, which require constant close monitoring and support from specialist, equipment and medication in order to ensure normal bodily functions. They are staffed by highly trained doctors and critical care nurses who have been specialized in caring for seriously ill patients. The complexity of the surgery, the surgeon's experience and skill, the operation time, intraoperative blood loss, and the patient's hemodynamics are indications that require ICU admission. [6] Measuring the quality of services provided in the ICU is very difficult because of the qualitative nature of such services, but the mortality rate in the ICU and the length of stay in the unit are two core indices for explanation of the offered services. [7] The ICU is one of the places where medical errors are likely to occur because of the complexity of patient care. [8] Furthermore, as the patients are heavily cared and simultaneously exposed to complex treatment interventions, they are highly susceptible to adverse effect. Although the possibility of human error in patient care in the ICU is high. [9][10] the cost of stay in ICU is a matter of great concern. [11][12] The ICU incurs a significant cost that accounts for 8 to 20 percent of total hospital costs.
Treatment of patients before their admission to ICU would possibly change the relation between the patient's physiological scoring and the patient outcomes. [7][8][13][14] Accordingly, the present study was performed on patients with corrective orthognathic surgery who  Table 1.
The results of the study suggested that gender had no effect on being admitted to the ICU or maxillofacial ward (p> 0.05) ( Table 2). The Mean±SD age of patients who were hospitalized in the maxillofacial ward was 24.08±7.3 years, while this number was 23.92±8.31 for those who were admitted to the ICU, but the observed difference was not statistically significant ( p > 0.05).
According to the results of the study, the average time of surgery for patients hospitalized in the ICU was 4.96±0.96 hours, and for the patients hospitalized in the maxillofacial ward, it was 4.11±1.21 hours, although the observed difference between the two groups was not significant (p> 0.05).  The findings revealed that patients in the ICU had lost more blood than the patient hospitalized in the maxillofacial ward, and the difference in blood loss between the two groups was statistically significant (p< 0.001) ( Table 3). The results showed that the ICU admitted patients suffered more from bleeding, nausea, vomiting, and pain than those who were hospitalized in the maxillofa-cial ward (p< 0.001) ( Table 5). As displayed in Figure   1a, there existed a negative relationship between age and the amount of blood loss during the surgery (r=-0.033), however, this relationship was not statistically significant (p> 0.05). It was also shown that there is a direct linear relationship between operation time and the estimated blood loss during surgery (r= 0.42), and this relationship was statistically significant (p< 0.001) (Figure 1b).  was not examined in their study.
In a study by Pineiro et al., [2] it was noted that bimaxillary surgery resulted in a major volume of blood loss which was directly related to the operation time and the magnitude of interventions. The results indicated a linear relationship between the operation time and intraoperative bleeding in such a way that longer operation time would result in more bleeding, and thus in higher morbidity rates and the need for more intensive care. Similarly, it was found that both the intensity of anesthesia and operation time was linearly correlated with morbidity after surgery, postoperative outcomes, and the need for hospitalization following the operation [17,23].
The results of the study indicated that patients who were admitted to the ICU experienced more pain, nausea, and bleeding than those in the general ward.
According to Azzam et al. [23] pain is common in the ICU. Besides, one of the complications of orthognathic surgery is pain. [17] A retrospective study by Silva et al. [17]  The results of the studies indicated that an increase in the operation time would raise the risk of nausea and vomiting. Sinclair et al. [24] found that the inci- were found in the catheter entry into the vein, 38% at the endotracheal tube site, and only 16% of bleedings had a gastrointestinal source; these reasons account for more than 50% of the causes of bleeding. [29] In another study, it was noted that coagulation abnormalities and stress-induced mucosal lesions are two of the most prevalent risk factors for significant bleeding in ICU patients. [28] In The findings also show that more experienced nurses at the ICU have an effective documentation experience (beneficial for maintenance of the treatment) compared to the initial documentation done by the less experienced nurses at the general wards.

Conclusion
Orthognathic surgery patients (maxillary impaction and setback plus mandibular advancement plus genioplasty) who experience more intraoperative bleeding, postoperative nausea, and pain would benefit from ICU admission after the surgery.